Manually after-loaded 192Ir low-dose rate brachytherapy after subtotal excision and flap reconstruction of recurrent cervical lymphadenopathy from head and neck cancer.

BACKGROUND: Treatment of extensive recurrent cervical lymph node metastases from previously irradiated head and neck cancer represents a difficult clinical challenge. We report the results of an approach of maximal surgical debulking and manually after-loaded intra-operative brachytherapy. PATIENTS AND METHODS: Seventy-four procedures were carried out at the Royal Marsden Hospital between 1979 and 2003. All patients had previously been treated with radical radiotherapy or chemoradiation. Patients underwent maximal surgical debulking, followed by brachytherapy to the tumour bed with low-dose rate (192)Ir to a dose of 60 Gy to the reference isodose using the Paris system. RESULTS: Overall and disease specific survival rates were 31% and 28% at two years and 23% and 17% at five years. Corresponding Loco-regional control rates were 37% and 23%, respectively. Fifty per cent of patients developed metastatic disease within 5 years of treatment. Best results were obtained with surgical excision, brachytherapy and reconstruction of the skin defect using a vascularised myo-cutaneous flap with in-field control rates of 72% at two years and 66% at 5 years. Nine per cent of patients developed fistulae, 4% had haemorrhage and 8% wound breakdown/infection. CONCLUSIONS: Maximal surgical debulking, including removal of overlying skin, and brachytherapy to the surgical tumour bed provides high levels of local control, and can be achieved with acceptable morbidity. Only a minority of patients achieve long-term survival because of the high risk of systemic relapse.

The SOOF lift: its role in correcting midfacial and lower facial asymmetry in patients with partial facial palsy.

Subperiosteal face lifting has gained wide acceptance in aesthetic surgical practice. It may also have a role to play in patients with partial facial palsy. These patients demonstrate poor static position of the mouth but maintain some degree of facial movement. This study examined the role of subperiosteal facial suspension as an alternative treatment modality in this patient group. In this series, five patients with varying degrees of partial facial palsy underwent subperiosteal face lifting, including sub-orbicularis oculi fat elevation via a temporal, lower lid, and buccal approach, thereby mobilizing and elevating and suspending the zygomaticus major and levator labii superioris muscles on the facial skeleton. An attempt was made to categorize the patients according to overall House-Brackmann score. It was not possible to precisely classify the patients by this method, although the approximate scores were two patients scoring 3, two patients scoring 4, and one patient scoring 5. To overcome inconsistencies with this method, the degree of static and dynamic asymmetry of the mouth and also the excursion of the mouth were graded separately. Four patients with mild to moderate dynamic and static asymmetry (House-Brackmann score of approximately 3 and 4) who maintained excellent or good excursion of the mouth achieved excellent or good results. One patient with poor excursion and severe partial facial palsy (House-Brackmann score of 5) was improved but remained markedly asymmetric (follow-up, 4 months to 1 year). Subperiosteal face lifting is a useful therapeutic modality for management of selected patients with mild partial facial palsy. These patients demonstrate asymmetric static position but maintain some degree of muscle excursion. Patients with severe facial palsies with poor muscle excursion continue to require muscle transfer or sling procedures. The authors hope that long-term follow-up will confirm the sustained effect of midfacial suspension in this selected patient group.

Arterial and venous anatomical features of the pectoralis minor muscle flap pedicle.

The pectoralis minor muscle has been used as an innervated, vascularized, free-muscle graft in the field of facial reanimation for 20 years. Throughout this period, several centers have demonstrated consistent success with functional muscle transfer; however, opinions regarding the arterial pedicle of the flap have varied. The lateral thoracic and thoracoacromial arteries have been proposed as the predominant arterial sources. It has been the experience of our unit that a vessel (not described in anatomy textbooks) arising directly from the axillary artery and entering the muscle from its dorsal surface provides the dominant supply to the flap and is capable of sustaining it for free-tissue transfer. The vascular pedicle encountered was recorded and photographed in 97 consecutive cases in which the pectoralis minor muscle flap was raised. The findings demonstrated that the dominant supply to the muscle was from a single artery in 77 percent of cases and took the form of an artery arising directly from the axillary vessel in 72 percent of cases. More than one major arterial source was noted in the remainder of the cases. The venous outflow was usually through single or multiple veins running directly from the muscle into the axillary vein.

Preservation of the lateral thoracic vein in axillary dissection - its role in breast reconstruction using the DIEP flap.

Axillary clearance is still an integral part of the surgical treatment of breast cancer. Despite evolution in surgical technique, some accessory axillary structures such as the lateral throacic vein, may be sacrificied in order to achieve and adequate oncological clearance. Recent years have seen rapid advances in onco-plastic surgery and its involvement in breast cancer patients. As many onco-plastic procedures necessitate an adequate blood supply, structures which were thought to be expendable such as the lateral thoracic vein, are now viewed as useful vessels for success. We describe the use of the lateral thoracic vein as a salvage option in the Deep Inferior Epigastric Perforator (DIEP) flap and encourage surgeons to preserve this vessels when appropriate and safe to do so.

Malignant melanoma and deep penetrating naevus--difficulties in diagnosis in children.

A 4-year-old boy presented to our department with a darkly pigmented lesion on the right side of his neck. It was excised and a diagnosis of deep penetrating naevus with atypical features was made. At 4-month follow-up our patient had developed a palpable cervical lymph node. Excision revealed malignant melanoma. We discuss our management and review the literature regarding DPN and melanoma of childhood.

Psychosocial outcome of patients after ear reconstruction: a retrospective study of 62 patients.

This was a retrospective study examining the psychosocial morbidity of patients before and after ear reconstruction. Semistructured questionnaires were sent to 90 patents with significant congenital or acquired auricular deformity 2.2 years (range 3 months to 5 years) following autogenous or osteointegrated reconstruction. Sixty-two patients (69%) responded. Twenty-two of the patients below 12 years, who had undergone reconstructive surgery, also completed the Childhood Experience Questionnaire. These were compared with a cohort of 362 normal patients. There was significant psychosocial morbidity in both children and adults with auricular deformity. Seventy-one percent of patients reported reduced self-confidence that affected both social life and leisure activity. Teasing was a prominent symptom in both children (88%) and adults (85%) but was a motivational factor for surgery in children only. Dissatisfaction with the appearance (73.1%), on the other hand, was the main reason for treatment in adults. Following ear reconstruction, 74% of adults and 91% of children reported an improvement in self-confidence resulting in enhanced social life and leisure activities in both adults and children. There was no difference between osteointegrated and autogenous reconstruction. Sixty percent of patients reported their result as excellent. The patients scored their result better than the surgeon. We conclude that auricular reconstruction has significant psychosocial benefit in the majority of children and adults despite donor-site morbidity and a range of technical result.